What are the treatment options for akathisia?

Treatment Options for Akathisia

For patients with akathisia, the recommended first-line treatments are lowering the antipsychotic dosage, switching to another antipsychotic medication, or adding a beta-blocker such as propranolol. 1

Understanding Akathisia

Akathisia is a distressing neuropsychiatric syndrome characterized by:

• Subjective feelings of inner restlessness and an urge to move 2
• Objective manifestations including rocking while standing/sitting, lifting feet as if marching, and crossing/uncrossing legs 2
• Potential severe distress that may increase suicide risk if left untreated 3

Treatment Algorithm

First-line Approaches (try these first):

1. Antipsychotic Medication Adjustments:

   • Reduce the dosage of the current antipsychotic while remaining within therapeutic range 1
   • Switch to an antipsychotic with lower akathisia risk (e.g., quetiapine or olanzapine) 1
   • Avoid antipsychotic polypharmacy which can increase side effect burden 1

2. Beta-Blockers:

   • Propranolol (10-30 mg two to three times daily) is the most consistently effective treatment 1, 2
   • Consider contraindications (asthma, certain cardiac conditions) before prescribing 4

Second-line Approaches (if first-line fails):

1. Benzodiazepines:

   • Add a benzodiazepine if beta-blockers fail or are contraindicated 1, 2
   • Particularly helpful for persistent subjective distress 2

2. Anticholinergic Agents:

   • Particularly useful if parkinsonian symptoms are also present 3
   • Monitor for anticholinergic side effects 1

3. 5-HT2A Antagonists:

   • Mirtazapine (7.5-15 mg once daily) shows compelling evidence for efficacy 4, 5
   • Other options include trazodone, cyproheptadine, mianserin 4

4. Additional Options:

   • Clonidine may be tried if other treatments fail 2, 5
   • Amantadine has shown some benefit in limited studies 2, 5
   • Vitamin B6, gabapentin, and pregabalin have preliminary evidence but insufficient data for strong recommendations 5

Monitoring and Assessment

• Use a validated scale to systematically assess akathisia before starting antipsychotics and during dosage titration 6
• Regularly reassess symptoms to determine treatment effectiveness 6
• Monitor for side effects of adjunctive medications 6

Important Considerations

• Akathisia can be misinterpreted as psychotic agitation or anxiety, leading to inappropriate increases in antipsychotic dosage that worsen the condition 1
• Early recognition and management improve prognosis 5
• Limit the duration of adjunctive medications when possible 6
• The "B-CALM" acronym (Beta-blockers, Clonazepam, Anticholinergics, cLonidine, and Mirtazapine) can help recall evidence-based treatment options 5

Special Situations

• For acute akathisia in emergency settings, intramuscular administration of medications is preferred over intravenous route 1
• In patients with tardive akathisia (late-onset), evidence for effective treatments is more limited 2
• For patients with high cardiovascular risk, carefully consider the QT-prolonging effects of certain antipsychotics when switching medications 1